Dark Circles Under the Eyes

Dear Lisa,

My nephew's skin color just under his eyes shows purple/red. Is this normal for a boy 1 month short of his second birthday? His mother has asked her GP however she was brushed off as if this was normal. It's beginning to worry her (and the family).

“Dark Circles Under the Eyes”

Dear “Dark Circles Under the Eyes”,

It is easier to notice color changes, discolorations and rashes on children with light colored skin. The melanin in dark colored skin masks other pigments, making it difficult to identify the pallor, redness or blue discoloration that is so readily seen in light skinned people.(1) Dark circles underneath the eyes are also more apparent on children with lighter skin. If a child develops a discoloration that is significantly more noticeable than his family members with the same skin tone, then other causes should be considered.

A purple discoloration underneath the eyes not associated with a rash, dryness or crusting may be due to “Allergic Shiners”. Children with Asthma, Allergies or a Sinus infection can develop “Allergic Shiner’s or dark purple circles under the eyes. These dark circles occur due to capillary congestion in the area and have nothing to do with the amount of oxygen that a child is getting.

“Allergic Shiners’ are considered an early warning sign for children with diagnosed Asthma. It is a sign that a child’s Asthmatic condition is worsening. Allergic Shiners are frequently found before a child develops an acute exacerbation of symptoms or an Asthma attack. Parents with Asthmatic children interpret Allergic Shiners as a signal that their child’s Asthma is out of control and that initiation of an Asthma Action Plan is necessary.(2)

Symptoms of Asthma include nocturnal cough, chronic cough, recurrent wheezing, episodic wheezing/cough associated with exercise, airway obstruction in response to a trigger, problems suckling, difficulty finishing a sentence, chest wall retractions, nasal flaring, paleness or cyanosis.(3). Early warning signs of Asthma are symptoms that occur prior to the development of these Ashtma symptoms. Other early warning signs include runny nose, cough, sneezing, change in personality, tightness in the throat and scratching the neck.

Children with Allergies, Eczema, a history of RSV in infancy, exposure to cigarette smoke or a history of recurrent wheezing have a greater chance of developing Asthma. (4,5,6) Major factors that predict the probability that a school age child will develop persistent Asthma include a personal history of Eczema and a parental history of Asthma.(7)

Children with Hay fever or Allergic rhinitis may also develop Allergic Shiners as one of their symptoms.(8) Other symptoms of Allergies include sneezing, itching, runny nose, nasal congestion, headaches, nocturnal cough, nasal itching, nasal rubbing, allergic salute, nasal crease, itchy throat, red eyes, watery eyes, irritability, reduced school performance, fatigue and loss of sleep. (9) Allergic rhinitis is often overlooked and under-treated because it is frequently mistaken for the common cold or recurrent upper respiratory tract infections.(9)

Children with Allergies have a greater risk of developing Sinusitis and recurrent ear infections.(10,11) Sinusitis is the inflammation of the lining of the nasal sinuses.(12) Sinusitis may present with symptoms similar to Allergic rhinitis. The symptoms of Sinusitis include cold symptoms for more than 7 to 10 days, increasing severity of cold symptoms after 5 to 7 days, fatigue, cough, fever, headaches, nasal congestion, eye pain, facial pain, toothache, foul tasting post-nasal drip, loss of sense of smell or taste, bad breath and learning difficulties at school (12,13) The interesting thing is that almost 50% of children with chronic sinusitis have positive skin test to environmental allergens. (13,14)

It is important to remember that skin conditions cannot be diagnosed without having your health care provider actually see and feel the affected area. I can’t tell you how many times I spoke to a parent on the telephone about their child’s rash and when the the child was seen in the office for an evaluation, the condition appeared totally different from what the parent described. This occurs because rashes may change over time and because rashes can be altered due to scratching or the application of medication or crèmes. The interpretation of a rash may vary depending upon the different experience levels of the person evaluating the rash.

It is essential that a Physician or Nurse Practitioner examine your nephew in order to come up with the proper diagnosis. It is important to note that “Allergic Shiners” are many times better appreciated by an Allergist or Pulmonologist who specializes in Asthma and Allergies in children. The education and experience that these specialists receive better prepares them to identify subtle changes found in children with Asthma and Allergies.

If your nephew already has Asthma, the changes around his eyes may be due to an exacerbation of this condition. If this is the case, it would be important to look for signs which show that his Asthma is out of control and report them to his doctor. Signs that a child’s Asthma is not under control include the need for rescue medication (Albuterol) more than twice per week, respiratory symptoms that affect his activity, waking at night due to respiratory symptoms occurring two or more times per month, chronic coughing and persistent night time coughing. (15) If your nephew has not been diagnosed with Asthma, Allergies or Sinusitis and is experiencing these symptoms along with this discoloration under his eyes then he needs medical attention.

Your nephew is very lucky to have a family that is so concerned about his health. It is also refreshing to see a family that can work together and jointly care for their childrens’ health conditions. This is not always the case, because many parents are sensitive about receiving health advice from family members.

It is always important to get a parent's consent to seek information and wise to give advice only when your opinion is sought. This can be very difficult for a family member who is concerned for a child’s health and who may have a more objective view of the whole situation. A caring and helpful approach is more likely to be well received.

References:
(1)Bates B. A Guide to Physical Examination and History Taking. Fifth Ed. Philadelphia, PA:J.B.Lippincott Company. 1991:140.
(2)National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. 1997. Bethesda, MD: National Institute of Health; 1997. NIH Publication 917-4051.
(3)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:265.
(4)Kumar R. The Wheezing Infant: Diagnosis and Treatment. Pediatric Annals. 2003. 32(1):30-36.
(5)Peebles RS. Viral infections, atopy and asthma: is there a causal relationship J Allergy Clin Immunol. 2004;113:S15-18.
(6)Sigurs N, Bjarnason B. Sigurbergsson F, Kjellman B, Bjorksyen B. Asthma and immunoglobulin E antibodies after respiratory syncytial virus bronchiolitis: a prospective cohort study with matched controls. Pediatrics. 1995;95:500-505.
(7)Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000;162:1403-1406.
(8)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 982.
(9)Mahr TA, Sheth K. Update on allergic rhinitis. Pediatr Rev. 2005;26:284-288.
(10)Berger WE. Allergic rhinitis in children: Diagnosis and Management Strategies. Pediatr Drugs. 2004;6:233-250.
(11)Huang S. Nasal Allergy and Sinus Infection: The Link-and Therapeutic Implications. Consultant for Pediatricians. 2006. June:345-352.
(12)Smart B. What you need to Know about Sinusitis. Asthma Magazine. 2002. Sept/Oct:38.
(13)Anon JB Otolaryngol Head Neck Surg. 2004. 130(Suppl): 1-45.
(14)Zacharisen M, Casper R. Pediatric Sinusits. . Immumol Allergy Clinics North Am. 2005;25:313-332.
(15)Hogan M, Wilson N. Asthma in the school-aged child. Pediatric Annals. 2003.32(1)20-25.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Children's Health